Behaviour Change Communication Strategy: Innovative Messages and Indigenous Tools

"One cannot emphasise enough the immense value that the mobiliser programme has been able to bring in the way in which social barriers have come down to the overall positive message[s] of the polio eradication programme."

Until 1998, the thrust of the polio eradication programme was on encouraging parents to bring their children to fixed booths/sites for vaccination, using mass media to promote awareness of dates when the vaccination booths would be functional. When house-to-house visits were introduced, the focus of the communication campaign was intended to inform families about polio transmission and prevention and the need to give their child the oral polio drops. This chapter from the document Influencing Change (see Related Summaries, below) details the key elements of the CORE Group Polio Project (CGPP)'s behaviour change communication (BCC) strategy as the organisation worked to eradicate polio from India.

As CGPP's BCC Advisor, Rina Dey, explains in the chapter, previously, the focus was on widespread distribution of information materials and outreach activities just before and during the oral polio vaccine (OPV) campaign. She says, "this prescriptive one-way messaging, which focused only on changing one behaviour without addressing other health needs, resulted in families questioning and doubting the intent of the vaccination efforts and soon transformed into resistance to the vaccine and vaccinators". Thus, mobilising the community was essential for gaining their trust in order to break the resistance to the polio vaccine that had become a barrier in achieving polio eradication. To do so, the programme had to understand the communities' needs and concerns and develop messages and materials that were not only technically sound but that also respected the attitudes and beliefs of the communities.

CGPP and their partners met to share the experiences that their mobilisers faced in the community. These data from the field helped improve understanding of social and cultural beliefs and concerns of the communities and brought greater focus and efficiency to planning communication activities. With improved data collection and behaviour analysis, CGPP segmented their audiences, designed and developed messages and materials, and used a mix of methods to achieve their defined objectives by:

• Sharing information with individuals and families to enable an informed choice;
• Motivating households and small groups;
• Identifying and involving influencers and communication networks to generate social pressure and motivate resistant families to vaccinate their children; and
• Involving community groups through participatory strategies (social mobilisation).

Based on research findings and behaviour change objectives, CGPP segmented the audiences for the communication efforts into: primary audience (mothers, fathers, and other caretakers of children below 5 years of age) and secondary audience (influential people such as relatives, neighbours, and community members).

As families asked, "why focus only on polio and not our other health needs?", it became evident that long-term change could not be brought about by only focusing on polio and polio vaccination messages. Thus, in addition to the polio messages, messages on routine immunisation (RI), exclusive breastfeeding, diarrhoea management, open defaecation, and hand washing were therefore also included in CGPP's package of communication messages.

CGPP and its partners used a multipronged communications approach that encompassed (i) interpersonal communication (IPC) (client-provider interaction); (ii) group meetings and community gatherings engaging community influencers, religious leaders, children, and mothers; and (iii) use of key community sites such as mosques, schools, or festivals to disseminate their BCC package and generate demand for health services. To cite only one example: Children's brigades (Bulaawa Tolies) would conduct a walk-about rally in their neighbourhood with banners and music prior to each polio vaccination round and on the vaccination day. Rooster rallies were also organised, where children would loudly sing "cock-a-doodle-do" (Kukuru-ku), a slogan accompanied by pictorial placards that were developed for promoting messages to discourage open defaecation, which is linked to polio transmission.

CGPP developed a set/kit of information, education, and communication (IEC) tools that were meant to be participatory and fun. A mix of print and electronic materials, games, and mid-media tools were developed and used in different activities/settings and with different audiences; they are described in the chapter. For instance, the snakes and ladders board game, which was adapted from a game played widely by children in India, was designed to promote learning about immunisation and other healthy practices while playing. During the course of the game, the players discuss the messages depicted in the illustrations to promote group learning and sharing. Among the many other methods discussed to convey information about polio prevention and booth day to a wider audience: street theatre, magic shows, video-vans, information-vans, and electronic rickshaw rallies.

To ensure mobilisers had the knowledge and skills to conduct quality community-based activities, CGPP conducted annual trainings that were highly interactive and used a variety of training methods, including group work and participatory sessions, problem-solving exercises, games, and role plays. The 3-day training module had 4 parts: (i) the basics of polio eradication and its vital link with RI; (ii) communication and counselling skills theory and practice focusing on the principles of health education, counselling for behaviour change, and strategies for recalling appropriate messages and dispelling myths; (iii) the practical use of programme-specific tools and methods for social mobilisation activities and IPC; and (iv) the use of registers for recording up-to-date information on households and institutions in a mobiliser's catchment area to be used for planning and implementing social mobilisation activities. An expanded 4-day version for training trainers also covered participatory training methods, facilitation skills, and needs assessments.

Periodically, CGPP held a full-day infotainment programme designed to acknowledge the contribution of field staff. The event consisted of a cultural programme where awards were presented to well-performing grassroots workers and volunteers. The function was presided over by the District Magistrate and Chief Medical Officer, thus providing an element of prestige to the event.

According to CGPP, achievements in the area of BCC included:

• Due to the implementation of the enhanced package of messages and information, the polio programme was perceived by the community as being interested in and committed to improving the overall health of children.
• Implementation of the BCC intervention had a positive impact on the level of mothers' knowledge about polio (see Figure 5 in the chapter).
• A survey of 1,786 mothers showed that the majority (78%) of them reported exposure to at least one IEC material provided by the mobilisers. Data showed that there was a high retention of the immunisation card.
• When the last case of polio was reported in Howrah, West Bengal, CGPP was invited to be part of the emergency response. They spent 2 years in that state from 2012, and dueto the success of the tools in the state of Uttar Pradesh (UP), they used the same BCC structure and tools. The tools were translated into Bengali, and the "Science of Polio" film, which was also used during the trainings, was given a voice-over translation.

According to Rina Dey, who is cited above, "research is key to planning an effective communication strategy that responds to local needs." She adds that research is also important for monitoring and evaluating the impact and effectiveness of any communication initiative. Also, she stresses that simple and indigenous messages and materials are essential for an effective BCC strategy. Adapting tools and materials in ways that are local and native to the communities enhances acceptability of the message being delivered. Dey adds that, "CGPP's strong commitment to capacity building of its frontline workers was a key factor that contributed to the quality and effectiveness of polio eradication efforts in India."

Editor's note: This is Chapter 3 in the document Influencing Change: Documentation of CORE Group's Engagement in India's Polio Eradication Programme, which is a collaborative effort of the CGPP and The Communication Initiative. Please see Related Summaries, below, to access it in its entirety.